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{"sheet":"Request for Funds","index":0,"n_rows":66,"n_cols":8,"rows_kept":66,"merged":[[0,3,0,8],[1,3,1,8],[2,3,2,8],[4,5,4,8],[5,5,5,6],[5,7,5,8],[6,3,6,8],[7,4,7,5],[7,6,7,7],[8,4,8,8],[9,4,9,8],[10,4,10,8],[11,3,11,4],[11,5,11,8],[12,3,12,4],[12,5,12,8],[13,3,13,4],[13,5,13,8],[13,10,13,13],[14,3,14,4],[14,5,14,8],[15,3,15,4],[15,6,15,8],[16,3,16,4],[16,6,16,8],[17,3,17,4],[17,6,17,8],[18,3,18,8],[19,3,19,8],[20,3,20,8],[21,3,21,8],[22,3,22,8],[23,3,23,8],[24,3,24,8],[25,3,25,8],[26,6,26,8],[27,3,27,8],[28,3,28,8],[29,6,29,8],[30,4,31,8],[32,3,32,4],[32,5,32,8],[33,3,33,8],[34,3,34,8],[34,9,34,12],[35,9,35,12],[38,3,38,8],[38,9,38,12],[39,9,39,12],[40,9,40,12],[43,9,43,12],[44,9,44,12],[45,9,45,12],[46,3,46,8],[50,3,51,4],[50,5,50,8],[51,5,51,8],[52,3,52,4],[52,5,52,8],[53,3,53,4],[53,5,53,8],[54,3,54,4],[54,5,54,8],[55,3,55,4],[55,5,55,8],[56,3,56,4],[56,5,56,8],[57,3,57,4],[57,5,57,8],[58,3,58,4],[58,5,58,8],[59,3,59,4],[59,5,59,8],[60,3,60,4],[60,5,60,8],[61,3,61,4],[61,5,61,8],[62,3,62,4],[62,5,62,8],[63,3,63,4],[63,5,63,8],[64,3,64,4],[64,5,64,8],[65,3,65,4],[65,5,65,8]]}
[]
[{"$nulls":3},"REQUEST FOR FUNDS FORM\nDIVISION OF HOMELAND SECURITY AND EMERGENCY MANAGEMENT"]
[{"$nulls":3},"*Fill out a separate form for each project.  Maximum allowed advance per request is 30% of approved project amount"]
[]
[{"$nulls":3},"   Public Assistance","   Hazard Mitigation Grant \n   Program","Other:          "]
[{"$nulls":3},"   Request For Advance","   Request For \n   Reimbursement","Request For Partial Payment",null,"Request For Final Payment"]
[{"$nulls":3},"APPLICANT INFORMATION"]
[{"$nulls":3},"DR. NUMBER AND NAME:       ",null,null,"P/W NUMBER:"]
[{"$nulls":3},"APPLICANT NAME:       "]
[{"$nulls":3},"STREET:       "]
[{"$nulls":3},"CITY/ZIP:       "]
[{"$nulls":3},"APPROVED PROJECT AMOUNT:"]
[{"$nulls":3},"TOTAL AMOUNT OF PRIOR PAYMENTS:"]
[{"$nulls":3},"AMOUNT THIS REQUEST: (Max advance 30% each request.  Total allowable: 75% of total approved project amount)"]
[{"$nulls":3},"MAIL CHECK TO:",null,"DEPOSIT CHECK FOR APPLICANT:"]
[{"$nulls":5},"BANK NAME:        "]
[]
[{"$nulls":5},"ACCOUNT #:        "]
[{"$nulls":3},"THE APPLICANT AGREES:"]
[{"$nulls":3},"1.   That the funds will be placed in a special and separate account."]
[{"$nulls":3},"2.   That the funds will be expended within 30 days of receipt. (Applies to Advances Only)"]
[{"$nulls":3},"3.   That the funds will be used only for approved actual eligible expenditures."]
[{"$nulls":3},"4.   That any funds received, which are in excess of the approved actual expenditures, will be promptly refunded\n      to the State upon completion of the project."]
[{"$nulls":3},"5.   Any interest earned while these funds are on deposit will be promptly refunded to the state."]
[{"$nulls":3},"6.   No additional funds will be provided until the applicant provides financial documents to DHS&EM verifying\n      expenditures for any prior funds issued."]
[{"$nulls":3},"7.   Reports on funds that are classified as advances or payment of federal share for small projects are required on\n      a quarterly basis detailing their status.  This requirement is mandatory even if no expenditures have occurred."]
[{"$nulls":3},"DATE:       ",null,"TITLE:       "]
[{"$nulls":3},"SIGNATURE:"]
[{"$nulls":3},"FOR DHS&EM USE ONLY"]
[{"$nulls":3},"APPROVED:                      ","DISAPPROVED:","AMOUNT: "]
[{"$nulls":3},"COMMENTS:       "]
[]
[{"$nulls":3},"DATE:       ",null,"TITLE:       "]
[{"$nulls":3},"SIGNATURE:"]
[{"$nulls":3},"DIVISION OF HOMELAND SECURITY AND EMERGENCY MANAGEMENT\nRequest for Funds Form (Page 2 of 2 for Advance and Small Project Federal Share Payments Only)"]
[]
[{"$nulls":3},"  I Certify:"]
[]
[{"$nulls":3},"That all estimates listed below will cover only services performed or material used exclusively in disaster \nrelief operations as authorized in the approved Project Worksheet and that the funds will be expended in a timely manner. Furthermore, any federal share payments for Small Projects not expended by the initial performance period will be returned to the State. If payment is for a Large Project Advance, funds will be expended within 30-days of being issued."]
[]
[{"$nulls":3},"  Date",null,"Signature of Applicants Authorized Representative"]
[]
[]
[]
[]
[]
[{"$nulls":3},"Please provide a detailed estimated breakdown on how your community, agency or \norganization intends to utilize the funds being requested in this advance."]
[]
[]
[]
[{"$nulls":3},"DESCRIPTION OF WORK TO BE COMPLETED\nWITH THIS ADVANCE or SMALL PROJECT FEDERAL SHARE PAYMENT:",null,"ESTIMATED START DATE FOR WORK: \nESTIMATED COMPLETION DATE: "]
[{"$nulls":5},"ESTIMATED COSTS:"]
[{"$nulls":3},"Force Account (In-house) Labor"]
[{"$nulls":3},"Temporary Hire Labor"]
[{"$nulls":3},"Materials"]
[{"$nulls":3},"Force Account Equipment"]
[{"$nulls":3},"Rental Equipment"]
[{"$nulls":3},"Contract"]
[{"$nulls":3},"Miscellaneous"]
[{"$nulls":3},"Mitigation"]
[{"$nulls":3},"Direct Administrative"]
[{"$nulls":3},"Supplies"]
[]
[]
[]
[{"$nulls":3},"TOTAL",null,{"$f":"SUM(F53:I65)","v":0}]